1235110677 NPI number — LACYONI MORAES, MD, PC

Table of content: (NPI 1235110677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235110677 NPI number — LACYONI MORAES, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LACYONI MORAES, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ABINGDON HEART CARE AND PREVENTION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235110677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
390 COMMERCE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ABINGDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24211-3876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-676-2211
Provider Business Mailing Address Fax Number:
276-676-0966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ABINGDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24211-3876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-676-2211
Provider Business Practice Location Address Fax Number:
276-676-0966
Provider Enumeration Date:
11/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MORAES
Authorized Official First Name:
LACYONI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
276-676-2211

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  0101225620 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 461930 . This is a "ANTHEM GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00055669 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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